PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 46 with 0 responses identified (past 2 years) 2 response window open 1,398 historic with 0 responses identified

Live tracking of every Prevention of Future Deaths report and the published responses identified for them under Regulation 28's 56-day deadline.

How response counts are interpreted — 56-day deadline, Judiciary.UK data

Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date. We rely on Judiciary.UK for response data, so this tracker shows published responses we have identified there.

A report with at least one published response is counted as having a response identified, even if not every listed addressee has a separate published response. Reports with 0 responses identified are split by whether the response window is still open, within the last two years after that window, or older than two years. This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.

Historic reports with 0 responses identified are more than two years old. Older reports may have received a response that was never made public. Treat these counts as a neutral data-coverage signal, not confirmed non-compliance.

33 reports include a non-response confirmed by the Chief Coroner. Show only confirmed →

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6,383 reports · Page 121 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
1 Apr 2014	Oliver Hiscutt Lack of mandatory formal paediatric child health training for GPs results in inadequate skills to assess and manage …	Department of Health and Social … General Medical Council Health Education England Royal College of General Practitioners Royal College of Paediatrics and …	0/5
1 Apr 2014	Vincent Gibson Police incident management suffered from unclear leadership, inadequate communication protocols, ineffective resource allocation, and unreliable electronic aids, compromising …	Independent Police Complaints Commission Northumbria Police	0/2
31 Mar 2014	Joseph Godfrey Care staff and paramedics lacked awareness of warfarin-related bleeding risks in elderly fall patients. Care home staff failed …	BUPA Care Homes BUPA UK Provision	0/2
31 Mar 2014	Valerie Hancox Farm bale chutes are routinely left lowered and unmarked on public highways, contrary to manufacturer instructions, posing a …	AGCO Ltd	0/1
31 Mar 2014	Deanne Smith The practice of dispensing large quantities of methadone to drug-dependent individuals over public holidays increases the risk of …	Bromley Drug and Alcohol Service United Pharmacy	1/2
28 Mar 2014	Sebastian Davies Hourly night observations failed to check for patient immobility or movement, potentially delaying detection of unconsciousness, and lacked …	Norvic Clinic	0/1
28 Mar 2014	Susan Poore Anti-depressant medication was associated with a deterioration in the patient's depression, leading to an uncharacteristic death, despite side-effect …	NHS England	0/1
28 Mar 2014	Rosemary Simpson The bus stop's location in a busy area creates poor visibility for buses, forcing unsafe lane changes and …	London Borough of Camden	0/1
26 Mar 2014	Lee Hollman The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication …	Horsham and Mid Sussex Clinical … Royal College of General Practitioners	2/2
25 Mar 2014	Caroline Pilkington North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically …	Department of Health and Social … North West Ambulance Service	4/2
25 Mar 2014	Margaret Walker Incomplete medication history, poor record-keeping, and failure to apply a defibrillator promptly by ward staff contributed to critical …	5 Boroughs Partnership	1/1
24 Mar 2014	Sean Morley The A444 stretch lacks pedestrian/cyclist warning signs, street lighting, and protective barriers, despite regular use by vulnerable road …	Warwickshire County Council	1/1
24 Mar 2014	Phyllis Barnes A visiting GP failed to recognise the seriousness of the patient's condition. Post-operative telephone follow-ups were inadequate, and …	Frimley Park Hospital NHS Trust North East Hampshire and Farnham … Royal College of Surgeons	0/3
24 Mar 2014	Jackson Chadd Concerns include inadequate supervision for junior paediatric staff, insufficient consultant oversight for out-of-hours admissions, failure to apply national …	Department of Health and Social … Frimley Park Hospital Royal College of Paediatrics and …	2/3
21 Mar 2014	Kerry Jacobs The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was …	Surrey and Sussex NHS Trust	1/1
21 Mar 2014	Derrick Plater There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. …	Cambridgeshire County Council	1/1
21 Mar 2014	Norma Sheppard The report describes confusion regarding the terms of the deceased's discharge from hospital to the care home, specifically …	Queens Hospital Burton Upon Trent	0/1
20 Mar 2014	Robert Jones CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay …	West Wales General Hospital Glangwili …	1/1
19 Mar 2014	Christopher Williams A critical defibrillator failed due to lack of daily checks and no cross-check system. The hospital also lacked …	St Mary’s Hospital Warrington	0/1
18 Mar 2014	David Chatburn The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic …	Department of Health and Social … Pennine Care NHS Trust Rochdale Heywood and Middleton Clinical … York House Surgery	1/4
17 Mar 2014	Daniel Taylor A specific downhill road section preceding a right-hand bend lacked appropriate warning signs or markings, warranting a review …	Casualty Reduction Team	0/1
17 Mar 2014	Charles Bradley Inadequate record-keeping and communication failures at Arrowe Park Hospital led to the patient not being expected upon transfer …	Arrowe Park Hospital	0/1
17 Mar 2014	Peter Banks A pedestrian crossing point was positioned too close to the main road. Protective railings should be extended and …	Casualty Reduction Team	0/1
14 Mar 2014	David Oldfield Concerns were raised about the appropriateness and justification of tasering the deceased, given discrepancies in officer accounts. Unjustified …	West Yorkshire Police Force	1/1
14 Mar 2014	Michael Tarratt There was an unacceptable 18-month lapse in communication between the drug and alcohol team and the GP. Services …	Leicestershire Partnership NHS Trust	1/1
14 Mar 2014	Gavin Roberts The current 60mph speed limit for a specific bend is too high, and warning signs are inadequate, particularly …	Rotherham Metropolitan Borough Council	1/1
14 Mar 2014	Matthew Simmonds An effective local action plan for commissioning complex care pathways for ventilated patient discharges is not shared nationally, …	NHS England	0/1
13 Mar 2014	Janette Sutherland A drainage channel and concrete headwall present a significant hazard to road users. A safety barrier is needed …	Caerphilly County Borough Council	2/1
13 Mar 2014	Jean James Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that …	City Hospitals Sunderland NHS Foundation …	1/1
13 Mar 2014	Noel Williams The coroner noted a failure to communicate haemoglobin level test results, which are an important factor in considering …	South Tees NHS Trust	0/1
12 Mar 2014	Stephen Tilbury Excessive vehicle speed in a residential area, despite an existing trief curb, poses a significant risk as the …	London Borough of Havering	0/1
12 Mar 2014	Wendy Brown Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of …	Swindon Borough Council	1/1
12 Mar 2014	Andrew Hall Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within …	National Offender Management Service North Tees and Hartlepool NHS … Tees, Esk and Wear Valleys …	1/3
11 Mar 2014	Teresa Lonergan The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare …	Eltham Park Surgery	0/1
11 Mar 2014	Lorna Cullen The coroner raised concerns about long-term liaison psychiatry nurse staffing levels covering hospital emergency departments, after evidence indicated …	NHS Medway Clinical Commissioning Group NHS Swale Clinical Commissioning Group	0/2
11 Mar 2014	Christopher Shapley Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the …	HM Prison Cardiff Home Office	0/2
11 Mar 2014	Afifa Qaisar Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure …	Tameside Hospital NHS Foundation Trust	0/1
11 Mar 2014	Saleh Ali Dalie This residential road has a history of multiple incidents and two fatalities, yet requested road calming, parking restrictions, …	Birmingham City Council West Midlands Police	1/2
10 Mar 2014	Craig Marren Trees and foliage at a blind left-hand bend significantly impede driver visibility, creating a dangerous road hazard that …	Tyersal Farm	1/1
10 Mar 2014	Derrick Rivers The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of …	Care Quality Commission Passmonds Care Home Rochdale Metropolitan Borough Council	0/3
6 Mar 2014	Natasha Raghoo The coroner identified concerns regarding staff training in cardiopulmonary resuscitation and defibrillator use, sporadic physical observations, the lack …	Partnerships in Care South London and Maudsley NHS …	1/2
5 Mar 2014	Barry Dillion Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting …	East Lancashire Healthcare NHS Trust	0/1
5 Mar 2014	Neil Carter There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of …	Care Quality Commission Priory Group	2/2
5 Mar 2014	Stephen Ellis A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient …	Department of Health and Social …	0/1
5 Mar 2014	John Fox Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.	St George’s Hospital	0/1
5 Mar 2014	Nellie Travis The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing …	Tameside Hospital NHS Foundation Trust	0/1
4 Mar 2014	Anne-Marie Katherine Ellement The Armed Forces' victim support code lacks specific provision for serious sexual assault victims within the military, and …	Armed Forces Minister Provost Marshall (Army)	0/2
4 Mar 2014	Ryan Pettengell Despite official closure and prior safety recommendations following multiple drownings, the site remains accessible to the public with …	Borough Council of King’s Lynn … Norfolk County Council Norfolk Police Sibelco UK Ltd	0/4
4 Mar 2014	Kathleen Border Inadequate and unclear signage for parking areas led to a delivery vehicle reversing outside a designated zone, causing …	Northwood Square	1/1
3 Mar 2014	Carl Morris Concerns are raised regarding gaps in the PADI system for auditing medical certificates for divers and ensuring instructors …	Professional Association of Diving Instructors	1/1